Falling out-of-network
with your pharmacy

Why this happens and protecting your bottom line.

December 13, 2022 | 5 minute read

Traffic was a mess and so was the grocery store, but you’re finally headed to pick up that prescription refill you’ve needed all week – your last errand of the day before you head home to start dinner. Your corner pharmacy continues the day’s streak of long lines and frustrated patrons but, after 15 minutes in line, you’re next. You approach the counter, provide your information, then the pharmacy tech returns with your prescription in hand. A few strokes of the keys and…“That’ll be $118.38, please.”

What?! For Atorvastatin?

You assure the technician there must be some mistake, you’ve been filling this prescription here for years and they have your insurance on file. After double and triple checking, she confirms the cash price due and refers you to your insurance company for further assistance. One thirty-minute call with your insurance company later, you’ve been informed your pharmacy is now out-of-network with your insurance provider. Now what?

This isn’t an unfortunate experience affecting only those customers of small boutique pharmacies or individuals with minimal essential coverage (MEC) health plans. Contract disputes between the pharmacy benefit managers and some of the nation’s largest drugstore chains have found millions of Americans scrambling to find a new pharmacy to avoid paying full cash prices. Pharmacy benefit managers (PBM) negotiate drug prices and prescription coverage for insurance companies and when these negotiations don’t go well, contracts are not renewed leaving the pharmacy out-of-network.

In situations like the historic fallout between Express scripts (PBM) and Walgreens (drugstore chain), each of the parties blames the other for asking for too much money. While customers may never know the whole story – they’re caught in the middle as more recently occurred with many United Healthcare Plan holders. Certain UHC plan holders, many of which purchased their prescriptions from the previously in-network CVS Pharmacy, were notified the chain would be out of network for new clients and upon renewal for existing clients. As stated in a notice from United Healthcare Oxford, clients were warned – “…all CVS pharmacies will no longer be a part of your plan’s network. If you continue to fill prescriptions at this pharmacy, it will be considered out-of-network and you may have to pay the full cost of your prescriptions.”

So, what can you do to ensure your family isn’t inconvenienced, financially or otherwise, when it comes to your prescription needs?

  1. Be sure to review the network participation for your plan during your providers renewal or enrollment period to make sure no changes have occurred. Network participation may vary based on market and state requirements.

  2. If your renewal period has recently passed and you didn’t do so at the time, refer to your benefit plan materials to determine your prescription coverage and copayments so you’re prepared the next time you need to fill a prescription.

  3. Consider the convenient online Pharmacy. Nationally licensed pharmacies like DiRx can send your prescriptions to you. We’ll even ship your order for free.

  4. Cash-pay pharmacies are always an option, even if you do have sufficient insurance coverage. Sometimes the cash-pay price will be lower than your negotiated copay as is often the case with DiRx.

Always remember that, as a consumer, you have options regardless of your coverage. Network variations aren’t the only details of your pharmacy benefit that can change upon your plan renewal. Which medications are covered, the circumstances for which they can be covered and even the amount of the copay are all subject to the contract between your providers PBM and the pharmacies in their network. Compare your options regularly to ensure that you’re getting the best price. When you do find yourself needing to transfer your prescription, be sure to inform your prescriber immediately so that they are responsive in confirming your prescription. Prescriptions and transfers must be confirmed by the prescriber prior to filling.

Make the switch to DiRx.

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